Anatomy

At some point during the first intake, almost every new client declares that her body is a “complete disaster”, pointing out everything from tight traps to herniated disks to bad knees. While it is important for us to discuss and address any areas of injury, I am always careful to gently steer the narrative away from “I’m a mess.” We are all in desperate need of a reframe in the way we view our bodies, myself included. I genuinely want to listen to everything a client has going on, and I always want my client to know that she is heard. However, I want to make sure we are also reworking the pathology paradigm, together. Bodies deserve more credit, and as scary or counter-intuitive as it may seem at times, we need to have confidence that our bodies “work”. For the most part, bodies are capable of functioning and healing very well, despite the presence of one or more conditions we consider pathologies, and even despite the presence of pain. Part of the tunnel vision in seeing only what’s “wrong” and the ensuing feeling of helplessness is ingrained in our system of allopathic medicine. I have already written a blog post explaining my philosophy around this here. Unpacking the fear of movement associated with pain and injury is another critical piece in healing. Perhaps the most important piece in this shift, however, is to look at how we conceptualize pain and attempt to better understand its mechanisms.

Thinking of our bodies as being “all messed up” breeds fear of movement, which is counterproductive to healing. We need to make some adjustments when dealing with an acute injury, but smart movement is not only possible but necessary. Strengthening the muscles that support an area of injury as well as any weakened muscles that cause compensation in other areas has been shown to improve overall function.

Gentle, fluid movement increases lymphatic flow, helps the muscles rid themselves of cellular waste, improves joint function and generally decreases pain. The more we are afraid to move, the less our bodies will ultimately BE ABLE to move. If instead of thinking of our bodies as “broken”, we think of them as awe-inspiringly capable, with a few caveats, we have a much better paradigm. This doesn’t mean we have to push through acute pain, continuing to run with an injured achilles tendon, for example. That would be detrimental to the body (and stupid – I’ve done it). This means we can’t be afraid of ALL movement, because there is inevitably some beneficial movement that can be done. These days, even Western surgeons have their patients up and moving just hours after surgery!

Of course the other piece to the fear of movement is the avoidance of pain, which is the tricky and complicated part – especially when we get into the realm of prolonged chronic pain. Chronic pain is still not fully understood. However, recent developments in pain science can help us decipher the multiple causes for pain and what it might actually be signaling. Here is a great article by Lorimer Moseley on pain. I will summarize his four key points:

Pain does not provide a measure of the state of the tissues. In human pain experiments, researchers were able to deliver a non-harmful noxious stimulus to the subjects’ nociceptors (pain receptors) and elicit a pain response, in the absence of actual tissue damage. In this case, the assessment is inaccurate: there is pain without tissue damage. In the reverse, there can be tissue damage without pain. In the now famous MRI study testing the correlation between herniated disks and back pain, asymptomatic herniated disks were found in 52% of the subjects who reported NO back pain. This experiment has been replicated multiple times, leading to the conclusion that a herniated disk does not necessarily cause back pain. Again, the relationship between tissue damage and pain is not always correlative nor causative – it’s not that simple.

Pain is modulated by many factors from across somatic, psychological and social domains. Pain is governed by the central nervous system and has been shown to be affected by emotional states, anxiety and stress. In my clinical experience, chronic back pain is often affected more by stress and anxiety than it is by anything at the tissue level in the back muscles themselves. Moseley mentions inflammatory mediators, as well, and through understanding the genomics work that my boyfriend does, I have come to see how chronic inflammation in the body can affect the nervous system and amplify pain. Our own attention to and expectation surrounding pain is yet another factor in pain modulation. Anecdotally, we have probably all had the experience of being engaged in a sport or other physical activity, and looking down to find ourselves lightly bleeding from a cut somewhere that we didn’t notice. Once we pay attention to the cut, it starts to hurt. Studies have shown that if we expect something to hurt, we report the pain as being more intense than if we don’t – and it is postulated that this phenomenon is related to anxiety and stress. Perhaps the most interesting related finding of the studies Moseley cited … believing pain to be an accurate indicator of the state of the tissues is associated with higher pain ratings, whereas believing that the nervous system amplifies noxious input in chronic pain states decreases the perception of pain. In other words, fear around the belief that pain means our bodies are damaged increases pain levels. This is not to say the pain is “all in our heads” – the pain is real, and the fear increases the actual pain.

The relationship between pain and the state of the tissues becomes less predictable as pain persists. As pain becomes chronic, changes occur in the neural pathways and they become sensitized, causing us to experience increased pain even when the painful stimulus no longer exists. Whitney Lowe, one of my favorite massage educators, explains sensitization very eloquently here and here. Essentially, the nervous system can become more sensitive to certain stimuli once exposed to pain over time. This is common in the case of trauma survivors, and once the sensitization exists, even a mild stimulus can elicit an extreme pain response. The two most common clinical manifestations of the changes in the sensitized nervous system are hyperalgesia (formerly painful stimuli become more painful) and allodynia (formerly non-painful stimuli become painful).

Pain can be conceptualized as a conscious correlate of the implicit perception that tissue is in danger. In other words, when our brains perceive that we are under threat, pain results as one of the outputs of the central nervous system. Pain is real and can feel debilitating. His point is that the pain output occurs as a result of the perception of threat, not because of the state of the actual tissue.

The good news is that our bodies are not all messed up!

Adopting more proactive beliefs about the body’s potential for good health can help us release some of our fears around movement. Understanding the effects of anxiety and trauma may empower us to seek out somatic therapy. Grasping the importance of proper methylation and controlling inflammation may lead us to seek out the guidance of a holistic practitioner. There is still room for massage therapy in this paradigm, too! Massage addresses the nervous system, and regular massages may help to alleviate some of the symptoms of central nervous sensitization. Additionally, massage encourages body awareness, which is key to understanding pain. It has been shown that even reproducing pain or eliciting a new sensation in a non-threatening environment can begin to rewire neural pathways. As massage therapists, we have the capacity to support agency in our clients by interpreting feedback and learning together how their pain works – we become their partners in shedding some light. For those of us on tighter budgets, simply educating ourselves on the role of the nervous system in pain management is incredibly impactful, as is finding a buddy who will support and encourage smart movement.

For many people, even the word “sphincter” causes their sphincters to contract. And yet, sphincters in our bodies are so vital to our health. Sphincters are circular ring-like muscles surrounding a bodily passage or opening. They are normally constricted, but they relax in order to allow passage through the opening. These muscles are all about either “letting go” or “allowing in”. There are over 50 sphincter muscles in the human body, most of them involuntary. The majority of them are found in our digestive tracts. There is one at the upper portion of the stomach, to prevent acidic contents from moving up into the esophagus (“hopefully”), as well as at the lower end of the stomach, in between the small and large intestine, and to control secretions from the liver, pancreas and gallbladder into the duodenum. We also have them in and around our eyes, to control the amount of light our eyes allow in, to blink and to keep our eyes closed during sleep. Of course, there are the all-important sphincters in our urethras and ani to control the excretion of our waste materials. We have two in each area, and one of each of these is (finally!) a voluntary sphincter. If we have so few voluntary sphincters, meaning ones we can actually control, then why bother talking about them?

I will rewind to the 1970’s and to perhaps the most famous midwife in the United States, Ina May Gaskin, author of Spiritual Midwifery and Ina May’s Guide to Childbirth. She dedicated her life to fighting for natural childbirth and for the right to birth at home. She contributed much to the midwifery movement over the past 45 years, but she is not without controversy. She has been credited with “The Gaskin Maneuver”, a method of resolving shoulder dystocia during childbirth, which she “borrowed” from a Guatemalan midwife, thereby appropriating indigenous ideas without proper attribution. She has also received criticism for putting forth “The Sphincter Laws”, rules by which she claims the vagina, cervix and anus abide. Her critics harp on these “Laws” because neither the vagina nor the cervix are technically structural sphincters, although she describes them as such. She also discusses the sphincters of the mouth and throat, but recent evidence has shown that the round muscle surrounding the mouth which was previously believed to be a sphincter is probably four separate muscles. Her anatomy piece can appear a little loosey goosey, in the eyes of her critics. However, I don’t believe it’s necessary to throw the baby out with the bath water. The fact remains that Gaskin attended over 1200 births as a midwife, and she helped thousands of other women indirectly. She is a birth expert – and while her style may not resonate with everyone, the patterns she recognized in birth should not be ignored. Perhaps a slight reframe is in order. It is my belief that her work surrounding the pelvic sphincters (or functional “sphincters”) can still have a lot of value. By these I mean the cervix (which is not a sphincter but functions as one during pregnancy and childbirth – explained here) and sphincter ani externus, the external voluntary muscle around the anal opening. Understanding how they work can help us relax and open up, which many women have found invaluable during childbirth. The good news is that you don’t have to be pregnant to keep reading, because these properties work for ease in bowel movements, too! (I hope it’s obvious that while I am drawing a parallel between childbirth and bowel movements in that both involve passage through a functional pelvic sphincter, I am in no way comparing or equating the two.)

From my experience, the following three properties of Gaskin’s Sphincter Laws are the most helpful to keep in mind for ease in “letting go”.

Relaxing the mouth miraculously seems to relax the “sphincters” at the other end. Holding tension in the mouth and jaw makes it harder to allow the vagina to open. In contrast, releasing tension in the mouth also releases tension in the pelvic floor, cervix and vagina during labor. Below are some great ways to do this. The same rules apply to the anal sphincter, so try doing any of these things during your next bowel movement to see if they make you more comfortable:

Laughter

Slow, deep breathing

Opening the mouth and making low, deep “sexy” sounds

Making “raspberries” or “horse lips”

Pelvic “sphincters” do not respond well to commands. If you have ever tried to command yourself to poop, you know this doesn’t really work. By the same token, trying to will the cervix or vagina to open during labor doesn’t work either – they don’t respond to pressuring. Instead, try using gentle coaxing through visualization. Imagine the vagina to be big, soft and open. Make this a mantra and repeat it out loud. Another trick learned from Penny Simkin, author of my favorite birth companion book (The Birth Partner), is focusing on the 3 R’s: Rhythm, Relaxation and Ritual. She writes about these in the context of pain coping, but these strategies work wonderfully to open the body’s southern sphincters, too – and not just during childbirth. (Most women I know have a morning ritual, which at least involves relaxation, to encourage them to get on what my boyfriend affectionately calls “the poop train”.)

Pelvic “sphincters” perform best in an atmosphere of intimacy and privacy. A quiet, calm environment with low lighting and the least number of people tends to work best. Before you say “Duh, Julie”, think about the environment in most hospitals! Bright lighting and lots of hospital staff coming in and out – this environment is not conducive to relaxing and opening. It is well documented that cervical dilation can be going along great at home and stop or reverse the minute a laboring mom reaches a hospital. I am not saying don’t labor in the hospital; if that is where a mom feels the most safe, that is where she should be. I am saying: 1. Relax at home for as long as possible before going to the hospital, and 2. Make the environment in the hospital as intimate and private as humanly possible.

I think of the pelvic floor sphincter muscles as the muscles of “letting go”. Understanding these three properties can help us let go with greater ease, regardless of whether we are discussing something as magical and otherworldly as childbirth or as mundane as the morning elimination.

When most of us think about our rear ends, we automatically think of our gluteus maximus muscle. This mighty muscle is large and extremely powerful, plus it is the most superficial and thus most visible muscle in that region of the posterior chain. However, just because it steals the spotlight doesn’t mean this muscle acts alone. The “glutes” consist of three muscles, each with a different yet important role to play in the activities of daily living. In addition to gluteus maximus, this muscle group also contains gluteus medius and gluteus minimus. In this post, I will highlight gluteus medius, because it is problematic for many of my clients (and for me, too!).

Anatomy:

Gluteus medius comprises the middle layer of the glute muscles. It originates on the lateral posterior surface of the ilium, or hip bone, and attaches to the greater trochanter of the femur, or the bony protrusion at the outer top of the leg bone. (If you prefer a video, here is a video.)

Function:

Gluteus medius is a powerful abductor of the leg, meaning it is the muscle we use when raising our leg out to the side. Since it has both anterior and posterior fibers, it is also responsible for both internal and external rotation at the hip. However, this muscle’s most important role in the body is that of pelvic stabilizer. It provides stability to the pelvis while standing on one leg, for example. Considering that we stand on alternating legs every time we take a step to walk, it becomes clear how important this little muscle is! During the gait cycle, each leg takes a turn holding up our entire body weight as the other leg leaves the ground and swings forward.

Pathology:

If gluteus medius is weak, when we lift and swing the opposite leg forward, we can not hold the pelvis up. In that case, that opposite hip dips down rather than being maintained upright.

Normally in order to compensate for this weakness, we use our back muscles to shift the torso over the affected hip in order to create more stability through an altered center of gravity, which in time can lead to the dreaded low back pain. (A recent study found that pregnant women with weak gluteus medius muscles were 6-8 times more likely to have back pain than their “non-weak” counterparts.) This weight shift can also result in torsion forces in the knee, which can contribute to knee pain. Other muscles, such as the tensor fasciae latae, which attaches to the iliotibial band, may compensate for the lack of hip stability, which can lead to painful inflammation of the IT band.

My mentor, Ed Buresh, underscores the importance of the gluteus medius by highlighting its relationship to the psoas, a muscle which has definitely reached celebrity status. Just as the psoas provides stability to the spine, the gluteus medius provides stability to the hips. The two must work together. The psoas is often identified as a source of low back pain. However, one of the things I learned from Ed early on is that if we ignore the role of the gluteus medius in that scenario, we are missing half of the equation. In my experience, the psoas tends to be tight and the gluteus medius tends to be weak.

The best way to gently build up weak gluteus medius muscles is to start incorporating non-weight bearing exercises, like the clam shell (figure to the right),

and gradually move toward more advanced movements like pelvic lists.

Here is Katy Bowman explaining the pelvic list:

For some in between exercises, here is an excellent resource I found online:

The gluteus medius is often overlooked, although it is commonly one of the weakest muscles in the hip and thus directly involved in various soft tissue dysfunctions. Becoming aware of the health of this muscle is key to maintaining proper gait biomechanics. In my clinical experience, most of us could benefit from incorporating some strengthening of the lateral hip into our weekly movement program.

In a perfect world, the shoulder would be one of the most mobile regions in our bodies. It is comprised of the shoulder (or glenohumeral) joint, the space where the arm connects to the body, and the shoulder (or pectoral) girdle, which includes the collarbone, the shoulder blade and their surrounding muscles. In both of these areas, there is great opportunity for movements in all planes of motion. However, despite the possibilities available in the anatomical “best case scenario”, the majority of us suffer from a general lack of flexibility in this region. Of course, each person has individual reasons for this and they are often multifactorial. However, one of the most common factors contributing to this decreased range of motion is too much time spent in static postures or a narrow range of repetitive movements. Being hunched over isn’t necessarily “the problem” – it’s being constantly hunched over for hours and hours without switching it up. Studies have shown that what is generally considered “good posture” has very little correlation with a lack of pain in the shoulder region (or anywhere, actually). Just as standing 100% of the time is not the fix for the discomfort caused by continual sitting, throwing your shoulders back and sticking your chest out 100% of the time is not the solution for hunching. Variety, as they say, is the spice of life. My clients who work at computers will inevitably spend a large part of their day with their arms in front of them, rotated inwardly, just as I will inevitably spend much of my day with my arm rotated so that I can put my forearm on a client’s body in front of me. We need to accept that SOME of these postures are unavoidable consequences of our biomechanical environment, but we have agency over how much movement we can sneak in even within limitations. If we are mindful of performing a variety of opposing movements, we can avoid some of the discomforts and range of motion issues experienced by our modern lifestyles. One simple way to focus on this is to periodically lengthen the muscles that become continually contracted through daily living. Stretching a muscle will not necessarily produce any permanent changes in muscle length, but introducing motion in a different direction can ultimately increase the range of motion. From my clinical experience, two of the main muscles that could benefit from this temporary lengthening on almost everyone are pectoralis minor and subscapularis, both in the shoulder region.

Pectoralis minor:

Pec minor is a small but very important muscle in the chest region. It originates on the surfaces of the third, fourth and fifth ribs and attaches to the coracoid process of the scapula, which is the little hook-like structure of the shoulder blade which sticks out on the front of the body. It pulls the shoulder blade medially, forward and down. In other words, when it contracts we end up in the “hunch” position. Click here for a 30-second video of pectoralis minor in action. Since many of us end up in this position chronically, it’s helpful to alternate our computer work / driving / massaging with short bouts of lengthening. The doorway stretch is excellent for accomplishing this and can be done any time we pass through doorway, or, for example, every time we get up to get water or on our way back from the restroom. Here is Brent Brookbush demonstrating proper form for this stretch:

Subscapularis:

Subscapularis is another muscle which can easily become chronically contracted. It is the internal muscle of the rotator cuff, originating on the interior surface of the shoulder blade (the part against the ribcage that we can’t normally touch) and attaching to the humerus of the arm. Other than the stabilizing function of the rotator cuff muscles as a group, subscapularis is responsible mainly for rotating the arm medially, or inward. Video here. Hunch posture starting to sound familiar? Performing a broomstick stretch once in a while to lengthen this muscle is an easy way to counteract that habit. I like Dr. Mandell’s version:

We may not be able to incorporate constant gentle movement into every moment of our days. If we have desk jobs, we are going to sit a lot and perhaps hunch a lot. The important thing is to try to switch it up when we can. These are but two easy ways to do that. Of course, you could also get your massage therapist to help you release these muscles too 🙂